 Enrolled in the Empire Plan? You must satisfy an annual deductible before being reimbursed for services performed by a non-participating provider. You are also responsible for 20 percent of covered charges until you reach the annual coinsurance maximum. The deductible and the coinsurance maximum increase on January 1st of each year. Beginning January 1, 2005: • The annual deductible for medical services and supplies from non-participating providers increases from $295 to $309, and • The annual coinsurance maximum increases from $1,419 to $1,486. The 20 percent coinsurance you pay for covered services by non-par providers counts towards this $1,486 maximum. Your copayments for services by participating providers also count. The changes to the deductible and coinsurance maximum are linked to the increase of 4.7 percent in the medical component of the Consumer Price Index for Workers for the period July 1,2003 through June 30, 2004. The Communicator will report in November on other changes to Empire Plan benefits for 2005. — Lorraine Simpkins |
Top court ruling doesn’t affect state employees The U.S. Supreme Court recently ruled patients who claim their HMOs inappropriately refused to pay for medical care their doctors recommended cannot sue for money damages in state court. The court sided with HMOs that claimed the only available remedy in such situations is in federal court under the Employment Retirement Income Security Act of 1974 (ERISA). This decision should not affect you if you’re enrolled in an HMO through the state Health Insurance Program (NYSHIP). Employee benefit plans, including health insurance plans established for government employees, are exempt from coverage under ERISA. NYSHIP is covered by this exemption and, therefore, is not an ERISA plan. So, you should be able to sue your HMO for damages in state court. New York state residents have two other sources of protection in the Managed Care Bill of Rights and the External Appeals Law. The Managed Care Bill of Rights spells out specific rights available to all HMO enrollees, such as the right to file a grievance, the right to change doctors in the plan and the right to see a doctor outside the plan if it does not have a doctor who can meet the patient’s health needs. The External Appeals Law allows a plan enrollee who has been denied coverage on the grounds that a service is not medically necessary, or is an experimental or investigational treatment, to gain access to a review outside the plan. After exhausting the plan’s internal review procedure, you can appeal to an external appeal agent certified by the state Department of Insurance to conduct such reviews. All health plans must provide information to enrollees about their right to an external appeal. — Deborah Stayman |
The
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